Trazodone
Trazodone (Desyrel, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico) is a psychoactive drug of the piperazine and triazolopyridine chemical classes that has antidepressant, anxiolytic, and hypnotic properties.1 It has been advertised that its therapeutic benefits become noticeable within the first week of administration. Trazodone has considerably less prominent anticholinergic (dry mouth, constipation, tachycardia) and sympatholytic (hypotension, sexual dysfunction consisting of erectile dysfunction and anorgasmia) side effects in comparison to most of the tricyclic antidepressants (TCAs) and tetracyclic antidepressants (TeCAs). History Trazodone was originally discovered and developed in Italy in the 1960s by Angelini research laboratories as a second-generation antidepressant. It was developed according to the mental pain hypothesis, which was postulated from studying patients and which proposes that major depression is associated with a decreased pain threshold. Trazodone was patented and marketed in many countries all over the world. It was approved by the Food and Drug Administration (FDA) at the end of 1981. It is closely related to nefazodone (Serzone).‎ Indications * Clinical depression with or without anxiety. * Insomnia. (in some countries, this is an off-label use) * Fibromyalgia, to aid in sleeping. * Control of nightmares or other sleep disturbances. Off-label and Investigational Uses * Panic disorder.1 * Diabetic neuropathy.2 * Bulimia nervosa.3 * Obsessive-compulsive disorder (OCD).45 * Alcohol withdrawal.678 * Schizophrenia and other psychoses.910 Antidepressant Augmentation Trazodone is often used in conjunction with selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac) and has been noted to help with the anxiety that can result from beginning treatment with such antidepressants. Trazodone has been prescribed to children as an aid to other antidepressants as well. Pharmacology Trazodone inhibits the reuptake of serotonin, but possesses a far lower affinity for the serotonin transporter (SERT) than the classical selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and citalopram (Celexa). Trazodone's anxiolytic and antidepressant effects may be due to its antagonistic effects at the 5-HT2A and 5-HT2C receptors.1 The compound's sedative effects may stem from its antagonist activity at the 5-HT2A receptor, alpha-1 adrenergic receptor and histaminergic H1 receptor. Pharmacokinetics Trazodone is well absorbed after oral administration with mean peak blood levels obtained at approximately 1 hour after ingestion. Absorption is somewhat delayed and enhanced by food. The mean blood elimination half-life is biphasic: the first phase's half-life is 3–6 hours, and the following phase's half-life is 5–9 hours. The drug is extensively metabolized with 3 or 4 major metabolites having been identified in man, some of which such as mCPP1 may contribute to the side effect profile of trazodone. mCCP has been shown to activate numerous serotonin receptors, including 5ht2c. Due to the short half-life of trazodone, if a dose is taken at night, mCCP would be present in the body during the following day, causing symptoms such as anorexia (behavioral symptoms), anxiety, hypolocomotion, headache, and depression. Approximately 70–75% of 14C-labelled trazodone was found to be excreted in the urine within 72 hours.2 Trazodone is highly protein-bound. Warnings * If the patient has a known hypersensitivity to trazodone. * If the patient is under 18 years of age (Antidepressant use in youth may increase the possibility of suicidal thoughts or actions).1 Precautions Trazodone is metabolised by CYP3A4, a liver enzyme.1 Inhibition of this enzyme by various other substances may delay its degradation, leading to high blood levels of trazodone. CYP3A4 may be inhibited by many other medications, herbs, and foods, and as such, trazodone may interact with these substances. One drug-food interaction is grapefruit juice. Drinking grapefruit juice is discouraged in patients taking trazodone. One glass of grapefruit juice occasionally is not likely to have this effect on most people, but drinking large amounts, or drinking it regularly is proven to affect trazodone's clearance. Despite the fact that only the CYP3A4 liver enzyme was initially thought to be involved in Trazodone's metabolism, later research has discovered it's active metabolite, mCPP is metabolized by CYP2D6, which explains the myriad of paradoxical symptoms experienced by poor 2D6 metabolizers and people who are prescribed 2D6 inhibitors (antidepressants, ADHD medications, OTC sleep aides) in combination with Trazodone. mCPP has been found to induce headache and anxiety when given alone, and inhibition of the CYP2D6 liver enzyme has been found to increase plasma mCPP, resulting in more unwanted side-effects that are not otherwise associated with Trazodone usage alone 62. The possibility of suicide in depressed patients remains during treatment and until significant remission occurs. Therefore, the number of tablets prescribed at any one time should take into account this possibility, and patients with suicidal ideation should never have access to large quantities of trazodone. Trazodone has been reported to cause seizures in a small number of patients who took it concurrently with other anti seizure medications.2 While trazodone is not a true member of the SSRI class of antidepressants, it does still share many properties of the SSRIs, especially the possibility of discontinuation syndrome if the medication is stopped too quickly.3 Care must therefore be taken when coming off the medication, usually by a gradual process of tapering down the dose over a period of time. A person who abruptly stops taking trazodone, even in doses as low as 25 mg (common for use as a sleep aid for people with anxiety disorders), may experience adverse mental reactions such as emotional instability, depressed mood, and suicidal thoughts. Although such warnings may be included in printed materials supplied with the drug, physicians prescribing trazodone, particularly those who are not psychiatrists, might not give oral warnings. Pregnancy and Lactation * Pregnancy: Sufficient data in humans is lacking. Use should be justified by the severity of the condition to be treated. * Lactation: Sufficient data in humans is also lacking. Additionally, trazodone may be found in the maternal milk in significant concentrations. Women should not breastfeed while taking trazodone. Side Effects The most common adverse reactions encountered are drowsiness, nausea/vomiting, headache and dry mouth. Adverse reactions reported include the following: Template:Fact Behavioral Drowsiness, fatigue, lethargy, psychomotor retardation, lightheadedness, dizziness, difficulty in concentration, confusion, uncontrollable laughter, sex drive increase. (Trazodone is also known to cause a "hangover effect" in patients prescribed the drug as a sleep aid: the "Trazodone hangover" generally ceases with regular use after three or four days.) Neurological Tremor, headache, ataxia, migraine, akathisia, muscle stiffness, slurred speech, slowed speech, vertigo, tinnitus, tingling of extremities, paresthesia, weakness, complex partial seizures, and rarely, impaired speech, muscle twitching, numbness, dystonia, euphoria, and involuntary movements. Autonomic Dry or numb mouth, blurred vision, priapism, diplopia, miosis, nasal congestion, constipation, sweating, urinary retention, increased urinary frequency and incontinence. Cardiovascular Hypotension, tachycardia, palpitations, shortness of breath, apnea, syncope, arrhythmias, prolonged P-R interval, atrial fibrillation, bradycardia, ventricular ectopic activity (including ventricular tachycardia), myocardial infarction, and cardiac arrest. Rare Side Effects Recent clinical studies in patients with pre-existing cardiac disease indicate that trazodone may be arrhythmogenic in some patients in that population. Arrhythmias identified include isolated PVC's, ventricular couplets, and in 2 patients short episodes (3 to 4 beats) of ventricular tachycardia. There have also been several post-marketing reports of arrhythmias in trazodone-treated patients who have pre-existing cardiac disease and in some patients who did not have pre-existing cardiac disease. Until the results of prospective studies are available, patients with pre-existing cardiac disease should be closely monitored, particularly for cardiac arrhythmias. Trazodone is not recommended for use during the initial recovery phase of myocardial infarction. Priapism Trazodone has rarely been associated with the occurrence of priapism. In approximately 33% of the cases reported, surgical intervention was required and, in a portion of these cases, permanent impairment of erectile function or impotence resulted. Priapism is a potentially harmful medical condition in which the erect penis does not return to its flaccid state (despite the absence of both physical and psychological stimulation) within about four hours. It is often painful. Male patients with prolonged or inappropriate erections should immediately discontinue the drug and consult their physician. If the condition persists for more than 24 hours, it would be advisable for the treating physician to consult a urologist or appropriate specialist in order to decide on a management approach. In women, a similar condition of persistent arousal can be caused and is called persistent genital arousal disorder. Gastrointestinal Nausea, vomiting, diarrhea, gastrointestinal discomfort, anorexia, increased appetite. Liver Rare cases of idiosyncratic hepatotoxicity have been observed, possibly due to the formation of reactive metabolites.1 Endocrine Decrease and, more rarely, increase in libido, weight gain and loss, and rarely, menstrual irregularities, retrograde ejaculation and inhibition of ejaculation. Elevated prolactin concentrations have been observed in patients taking trazodone.2 Allergic or Toxic Skin rash, itching, edema, and, rarely, hemolytic anemia, methemoglobinemia, liver enzyme alterations, obstructive jaundice, leukocytoclastic vasculitis, purpuric maculopapular eruptions, photosensitivity and fever. Miscellaneous Aching joints and muscles, hypersalivation, chest pain, hematuria, red, tired and itchy eyes.Template:Fact muscle twitches Occupational Hazards Since trazodone may impair the mental and/or physical abilities required for performance of potentially hazardous tasks, such as operating an automobile or machinery, the patient should be cautioned not to engage in such activities while impaired. Laboratory Tests It is recommended that white blood cell and differential counts should be performed in patients who develop sore throat, fever, or other signs of infection or blood dyscrasia and trazodone should be discontinued if the white blood cell or absolute neutrophil count falls below normal. Drug Interactions Trazodone may enhance the effects of alcohol, barbiturates and other CNS depressants; patients should be cautioned accordingly as trazodone with the combination of another CNS depressant, can result in extreme tiredness and dizziness. Increased serum digoxin and phenytoin levels have been reported to occur in patients receiving trazodone concurrently with either of those 2 drugs. Little is known about the interaction between trazodone and general anesthetics; therefore, prior to elective surgery, trazodone should be discontinued for as long as clinically feasible. Because it is not known whether an interaction will occur between trazodone and monoamine oxidase inhibitors (MAOIs), administration of trazodone should be initiated very cautiously with gradual increase in dosage as required, if an MAOIs is given concomitantly or has been discontinued shortly before medication with trazodone is instituted. Because of the absence of experience, concurrent administration of electroconvulsive therapy should be avoided. Dosage Treatment should be started with low initial doses of 25 to 50 mg daily in divided doses or in an evening single dose. The dose may be increased slowly to a maximum of 300 mg daily in ambulatory patients and to 600 mg daily in hospitalized patients. Geriatric and emaciated patients should begin with 25 mg daily; this dose may be slowly increased to 300 mg. The duration of treatment should be at least one month. A 50 mg dose is recommended when using Trazodone as a sleep aid. Overdose Symptoms Overdose of trazodone may cause an increase in incidence or severity of any of the reported adverse reactions, e.g. excessive sedation. Death by deliberate or accidental overdosage has been reported. However, trazodone is often used instead of tricyclic antidepressants because it is very rarely lethal in overdose. Depressed patients are therefore unlikely to successfully commit suicide with trazodone. Treatment There is no specific antidote for trazodone. Management of overdosage should, therefore, be symptomatic and supportive. Any person suspected of having taken an overdosage should be evaluated at a hospital as soon as possible. Activated charcoal, gastric lavage, and forced diuresis may be useful in facilitating elimination of the drug. See also *Selective serotonin reuptake inhibitor